Over the years, I have consulted and treated hundreds of runners, from average joggers to marathoners, professional athletes and high school athletes. Foot and ankle injuries, including plantar fasciitis, Achilles tendonitis, fibularis tendonitis and posterior tibialis strain are the most common we see among this population. Treatment for these types of injuries presents additional challenges when dealing with runners given the nature of their injuries, typically chronic/overuse type injuries, and the typical runner's propensity for training "through the pain."
A speedy recovery for runners, like all athletes, is paramount. This fact underscores the need as a clinician to appropriately identify the nature of the problem from a biomechanical standpoint and everything contributing to it, and then implement a treatment approach addressing what's been identified through our evaluation as comprehensively as possible.
With treating foot and ankle injuries, it is easy to develop tunnel vision, focusing too narrowly on the affected tissues and not adequately considering the big picture. Beyond the specific injury, adjacent structures need to be assessed and treated for their potential role in the cardinal complaints. In addition, patient education about factors such as training routines, early injury recognition, footwear and overall conditioning needs to be a substantial part of any treatment plan. This will minimize recovery time and maximize efforts for prevention of future occurrences
Localized Treatment
As with any injury, managing symptoms and promoting tissue healing is initially the primary focus. There is a wide variety of therapeutic exercises, manual techniques and modalities that can be employed to assist the body's ability to heal. Balancing all of these options has proven a key factor for success in my experience. The most common modalities we utilize include various forms of heat or ice, and educating patients about when to use either is important. It is also significant to avoid the habit of "icing after every treatment" or using heat before every treatment. Consider exactly what the desired treatment and tissue response is and apply the modality (or not) that best aids in that effort.
Manual techniques: Manual techniques including joint mobilization and stretching, traditional soft-tissue manipulation and IASTM (instrument-assisted soft-tissue mobilization) can improve circulation, tissue remodeling and joint mobility, as well as modulate pain. Plantar fasciitis and tendonitis injuries tend to respond particularly well to the appropriately implemented manual techniques.
Therapeutic exercise:This involves prescribing exercises that promote ROM, healthy blood flow and oxygenation of tissues, along with joint lubrication, below a threshold that exacerbates the inflammatory response when dealing in the more acute phases of injury. Using very light resistance with high repetitions (i.e., three sets of 30 for each exercise) helps promote healing but it is imperative that patients adhere to the prescribed number of exercises and not exceed the threshold that will exacerbate their condition. Once out of the acute phase, more traditional PREs become the focus to promote localized strengthening and neuromuscular control.
Therapeutic taping: A growing trend over the recent past is the use of elastic therapeutic tape, which has been made popular by professional athletes from all the major sports and Olympians. Therapeutic taping is used to augment traditional physical therapy in an effort to help relieve pain and sore muscles, enhance function and facilitate the healing process.
Therapeutic tape is a lightweight, "breathable" elastic tape with a long-lasting adhesive that is extremely durable. One theory is that the tape helps support muscles and improve the stability of joints that are in a particularly weakened state from overuse/strain or injury. It is also said that the elastic composition of the tape enables "lifting" of the skin at the injured site, resulting in increased blood flow and a reduction in the perception of pain. In these ways, elastic therapeutic tape may help to speed healing and rehabilitation.
The application and positioning of the tape is key. Depending on the type of strain or injury involved, the tape may be used to limit or promote movement. This modality, when used and applied correctly, has been reported to help runners reach their therapeutic goals in a timelier manner.
Kinetic chain and muscle imbalance: The fundamental problem we see with the majority of our runners and their associated foot and ankle injuries involves muscle imbalance/weakness beyond the lower leg itself. It is important to establish a strengthening program that addresses potential weakness in the trunk, hip and upper-thigh muscles, using functional movement patterns promoting synergy for neuromuscular control. Reinforce the basic concept: Control and stability of a distal extremity requires strength and stability proximally.
Training habits: Overtraining is one of the more common contributing factors involved in the onset of ankle tendonitis injuries and plantar fasciitis in more serious runners. In an effort to improve stamina and endurance, early warning signs of injury are often ignored as the intensity and frequency of training increase. As tissues break down in response to these increased challenges, the body's ability to respond and repair may not always be able to keep pace, eventually leading to injury.
Every injury and individual has a different threshold, which is why educating patients about the overall concept and how they can control it through training modification is so important. As a simple part of this training management, teaching runners the importance of avoiding abrupt changes in their regimen like excessively increasing miles, speed or intensity goes a long way in avoiding injury.
By Brendan Carman, PT, MPT, ATC